A Simple Interscalene Block: The Manani's …Keywords:Interscalene block, Supraclavicular block,...

Article ID: WMC004137 ISSN 2046-1690

A Simple Interscalene Block: The Manani'sTechnique. Some Elements Of Distinction FromSupraclavicular Perivascular TechniquesCorresponding Author:Dr. Gastone Zanette,Senior Lecturer in Anaesthesiology, University of Padua, Department of Neurosciences,Chair of DentalAnaesthesia, via Venezia 90, 35125 - Italy

Submitting Author:Dr. Gastone Zanette,Senior Lecturer in Anaesthesiology, University of Padua, Department of Neurosciences,Chair of DentalAnaesthesia, via Venezia 90, 35125 - Italy

Article ID: WMC004137

Article Type: Original Articles

Submitted on:22-Mar-2013, 03:35:05 PM GMT Published on: 23-Mar-2013, 06:59:47 AM GMT

Article URL: http://www.webmedcentral.com/article_view/4137

Subject Categories:ANAESTHESIA

Keywords:Interscalene block, Supraclavicular block, Subclavian perivascular block, Anatomical landmarks,Brachial plexus anatomy, Omohyoid muscle

How to cite the article:Manani G, Facco E, Zanette G. A Simple Interscalene Block: The Manani's Technique.Some Elements Of Distinction From Supraclavicular Perivascular Techniques . WebmedCentral ANAESTHESIA2013;4(3):WMC004137

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A Simple Interscalene Block: The Manani'sTechnique. Some Elements Of Distinction FromSupraclavicular Perivascular TechniquesAuthor(s): Manani G, Facco E, Zanette G

Abstract

Aim: The aim of this study is an anatomical reviewregarding the brachial plexus and its relationships withcontiguous anatomical structures to better define theInterscalene Brachial Plexus Block Technique alreadydescribed by Manani (IBPBTM), specificallyconcerning the point of needle penetration, needledirection and its relationship with OmoClavicularTriangle (OCT) and the inferior belly of omohyoidmuscle. Moreover, IBPBTM was compared with otherSupraclavicular Perivascular Brachial Plexus BlockTechniques (SPBPBT).

Materials and methods: The IBPBTM was performedin 80 randomly selected patients scheduled forshoulder surgery. After identification of the OCT andinferior belly of omohyoid muscle, fascial clickperception and evocation of adequate muscularcontractions, injection of 30 ml of 0.5% bupivacaine inthe interscalene space (IS) was performed; the anglesdelimited by the penetrating needle on the transverseand frontal planes, going across the cutaneouspenetration point, were measured and recorded.Moreover, the time of complete anaesthetic blockdevelopment and failure rate were evaluated bymeans of an electric stimulation applied on the skin ofC3-T1 dermatomes.

Results: In almost all patients identification of theOCT, omohyoid inferior belly muscle and fascial clickperception were possible. The stimulating needleresulted to be directed with a 14.0±5.2 and

-5.1±1.3 degree angle to the frontal and transverseplanes going across the cutaneous penetration point,respectively. Deep surgical blocks developed morerapidly on C3, C4 and C5 dermatomes, with respect tothe C6, C7, C8-T1 dermatomes. Failure rate wasabout 8%.

Discussion and conclusions: Our results confirm theefficacy of the IBPBTM and provide new insight for abetter performance of this block, specifically regardingto the needle penetration angles, the identification ofprecise anatomical landmarks (OCT and omohyoidinferior belly muscle). The block efficacy was

dependent on a correct performance, including theidentification of the IS located medially, behind andabove the OCT; on the contrary, in the SPBPBT theneedle penetration points are located inside the OCT.From this comparison IBPBTM seems to be superiorto SPBPBT in shoulder and peri-shoulder surgery.

Introduction

Previous studies have shown that interscalenebrachial plexus block techniques can be divided intotwo types of approach depending on whether the localanesthetic solution is injected in the vicinity of thespine or in the thickness of the interscalenic space(IS). In the first case, the area of anesthesia is largerdespite lower volumes of local anesthetic; in thesecond case, the area of anesthesia is more limited,mainly correspondent to the area of innervation of theprimary upper trunk of the brachial plexus. Greaterextension of the area of anesthesia, using eachtechnique may be achieved using higher volumes oflocal anesthetic.(1,2) Anesthesia of the brachial plexusinnervation area can also be obtained in other ways,among which the supraclavicular and subclavian way.(3)

The different ways of approach have generated amultiplicity of techniques, some of which are easy toperform, while others have a more difficult executionand are associated to a higher or lower incidence ofsuccess due to the complex anatomy of the region.Anatomical knowledge, acquisition of techniques andtheir application depending on the surgicalrequirements, respecting the principles of thetechniques used and the skill gained fromfrequentexecution of the block, all contribute to excellentresults. In this study we want to review ourInterscalene Brachial Plexus Block Technique alreadydescribed by Manani (IBPBTM) (4,5,6,7) along with acomparison of this block with other SupraclavicularPerivascular Brachial Plexus Block Techniques(SPBPBT), in relation to the anatomy of the brachialplexus; moreover, we want to describe more carefullythe needle direction, angles and point of penetration.Studying the anatomy of the region we have identifiedan additional area represented by the inferior belly ofthe omohyoid muscle that makes the IBPBTM



impossible to compare to the SPBPBT when theomohyoid muscle is easily identified.

Anatomy of the brachial plexus in relation to theexecution of IBPBTM and SPBPBT.(8)

The brachial plexus is located at the base of the neckin the supraclavicular fossa and consists of theanterior branches of C5, C6, C7 and C8 and the anteriorbranch of T1. (Illustration 1) The plexus is divided intosupraclavicular and subclavian portions. Thesupraclavicular part of the plexus consists of theanterior branches and the primary trunk. Where thesupraclavicular part of the plexus joins with thesubclavian artery it is referred to as the neurovascularbundle of the subclavian artery (Illustration 2). Theneurovascular bundle extends caudally in respect toan imaginary plane between the clavicle and the upperpart of the body of the 7th cervical vertebra. TheSPBPBT execution area, including the Winnie andCollins(9) and the "classical technique" by Kulenkampff, (10)

l ies below this plane (I l lustrat ion 3). Thesupraclavicular part of the brachial plexus nervesheath is surrounded by the IS(8) inside of which, theneedle must be inserted in order for the technique tobe included among the interscalene block techniques(Illustration 4). The subclavian portion includes thesecondary trunk, the origin of the long ramus and it issuitable for the infraclavicular and axillary blocktechniques.

The anterior and middle scalene muscles areimportant for the anaesthesiologist because thecervical and brachial plexus lie between them.(Illustration 5) The anterior scalene muscle is crossed,in the supraclavicular fossa, by the inferior belly of theomohyoid muscle. (Illustration 6) Between the anteriorand middle scalene muscle there is a pyramidal spacethat contains the brachial plexus and, at the bottom,also the subclavian artery, the so called "inter-scalenetriangle"(11) (Illustration 7). The anterior scalenemuscles define a depression called inter-scalenegroove. The brachial plexus, bonded to the middlescalene muscle through a fibrous lamina, emerges onthe lateral margin of the anterior scalene muscle.Emerging between the two scalene muscles, theplexus draws the apex of the inter-scalene trianglelocated above the upper edge of the omohyoid muscle.The block techniques performed above this landmarkare “true interscalene” blocks, like our IBPBTM,because the local anesthetic are introduced throughthe interscalene sheath in the correspondent groove.The subclavian artery is in relation with the brachialplexus, medially to the scalene muscles, then inbetween and finally, lateral to the scalene muscles. It

is important to note that the subclavian artery runs inthe triangle between the anterior scalene muscle, theomohyoid muscle and the clavicle, also called "theomoclavicular triangle" (Illustration 8).(12) Here, thesubclavian artery is in relation to the brachial plexusnerves.(13) The arterial pulsations perceived representan useful landmark for the performance of SPBPBTand IBPBTM. The omohyoid muscle demarcates thelimit between the inferior part of the brachial plexus,organized as neurovascular bundle by the addition ofsubclavian artery, and the superior part of the brachialplexus which is yet to be formed in the neurovascularsubclavian bundle. The brachial plexus is not formedin the neurovascular bundle when, coming out fromthe anterior and medial scalene muscles, it does notcome in relation with the subclavian artery. (14)

Approaches below this landmark (omohyoid muscle)must be defined as Supraclavicular PerivascularBrachial Plexus Block Techniques (SPBPBT) whileapproaches above this landmark must be defined asInterscalene Brachial Plexus Block Technique (IBPBT)as that already described by Manani (IBPBTM).(4)

The neurovascular bundle (subclavian artery andbrachial plexus) is wrapped by sheaths of thin anddense fibrous lamellar connective tissue connected tothe medium and deep cervical fascia.(15,16,17,18) Sincethis sheath continues with the sheath of the cervicalplexus,(19) a single injection of a large volume of localanesthetic in the IS is sufficient to obtain acervico-brachial plexus block.

Bias in performing brachial plexus blocks.

These notes about brachial plexus anatomy andrelations with contiguous structures, especially withthe subclavian artery, suggest that there are somefactors that influence the spread of the local anesthetic.Illustration 9 shows the typical distribution of surfaceanesthesia after IBPBT, SPBPBT, axillary techniqueand after the combination of IBPBT and axillarytechnique. Finger pressure was used to impede orfacilitate the cephalic progression of the localanesthetic after IBPBT, though Urmey et al.(23) deemthere to be no difference in the extension ofanesthesia. The search for the "fascial click”, for localanesthetic reflux,(24) for the paresthesias,(25) and formuscle contraction during electric stimulation(26,27) arethe prerequisites for the proper execution of the block.These methods seem to be surpassed by the recentultrasound-guided techniques.(28) The direction of theneedle is very important to reach the target. Whenusing IBPBTM, the correct execution requires directingthe needle towards the interscalene groove and the IS,although the secondary extensions of connectivetissue that wrap the blood vessels and nerves(29) can



be a barrier to the spread of the local anesthetic withinthe neurovascular space.

SPBPBT and IBPBTM: common and differentfeatures.

The SPBPBT.

The SPBPBT has anatomical landmarks which can beused all together or in part. (30,31,32,33) These points are: a)the middle part of the clavicle; b) the outer edge of theclavicular head of the SternoCleidoMastoid muscle(SCM); c) the inner edge of the trapezius muscle atthe clavicular insertion; c) the pulsation of thesubclavian artery d) Sedillot's triangle which is definedby the two heads of the SCM and the upper margin ofthe clavicle e) the external jugular vein; f) anteriorscalene muscle g) the omoclavicular triangle. SPBPBToccurs when the needle goes through theomoclavicular triangle area involving the primary trunkof the brachial plexus. Kulenkampff's SPBPBT(10) alsocalled "traditional technique", adjusted by Winnie andCollins(9) and the techniques of Alemanno et al.,(34)

Vongvises and Panijayanon,(35) Dupre and Danel(34)

and the plumb bob technique essentially consist ofinjecting the local anesthetic in the subclavianperivascular space using a supraclavicular approach.For this reason they are simply called "supraclavicularblocks." The common feature of these techniques isrepresented by the penetration of the needle in theomoclavicular triangle with many different orientationsof the needle, in respect to to the cranio-caudal axis inthe techniques of Kulenkamff,(10) Winnie and Collins,(9)

Vongvises and Panijayanond(35) and Dupre andDanelàs.(36) The axis of the syringe in Winnie andCollins,(9) Vongvises and Panijayanond(35) and Dupreand Danel(36) techniques is oriented towards the arterialgroove of the first rib in the cranio-caudal direction withthe risk of an unintentional puncture of the subclavianartery in 20-25% of cases.(37,38) In the plumb-bob andAlemanno's(39-41) techniques, the target is the brachialplexus located in the inferior-medial supraclavicularfossa and the risk is haematoma formation aftersubclavian artery puncture. The injection of localanesthetic in the subclavian perivascular space,whose section draws a circular surface (Illustration 3A)or ellipsoidal (Illustration 3B) depending on theSPBPBT used, causes a predominant nerve blockfrom C5 to C8.

The IBPBTM.

IBPBTM involves the injection of local anesthetic intothe IS space after penetrating the IS sheath, where thebrachial plexus has not yet met the subclavian arteryto create a neurovascular bundle with ellipsoidalsurface section (Illustration 3B). Therefore, if the local

anesthetic injection happens with the piercing of the ISsheath above the inferior belly of omohyoid muscle,the technique, obviously, must be cal led"INTERSCALENE brachial plexus block technique"(IBPBT). Therefore, IBPBT includes the techniques ofWinnie(17), the "double-needle technique" of Pippa et al.(42)

and the Manani’s technique(4). The injection of localanesthetic into the IS causes a predominant nerveblock from C2 to C5.

Complications: SPBPBT and IBPBTM can cause anumber of complications which include pneumothorax(incidence of 0.5 to 5.0%), the Claude Bernard-Hornersyndrome (incidence of 70-90%), vascular punctures,spinal anesthesia,(43,44), in particular, using Winnie'stechnique.(17) Finally, there are several neurologicalcomplications and unilateral diaphragmatic paralysiseven after a low IS block (45 ) associated withunnoticeable changes in respiratory volumes.(7,46) WithSPBPBT, the unilateral diaphragmatic block effect isless frequent, because the different anatomicallocation of the phrenic nerve on the anterior scalenemuscle.(34,46)

Methods

The patients: The research was carried out on 80subjects, randomly selected and scheduled forshoulder surgery in the Orthopaedic Department of theUniversity of Padua, after approval of the EthicsCommittee of the Department of Medical and SurgicalSpecialities of Padua University.

Patients age was between 49 and 80 years, of bothgender. The patients physical and anthropologicalparameters are shown in illustration 10. Patients wereinformed in detail about the technique of regionalanesthesia they would undergo. In particular, theywere informed that, on the involved arm, they mightexperience heat sensation, tingling and loss ofsensitivity up to a loss of muscle strength. Furthermore,they had been informed about possible side effects ofthe regional anesthesia technique. Consent wasobtained in accordance with the Hospital of Padua No.776 of 5 July 2010 through the acquisition of aconsent/refusal form for the proposed treatment.Patients with respiratory problems or cognitiveimpairment and patients scheduled for day surgerywere excluded from the study.

The technique: The block technique had beenperformed in accordance with the procedure alreadydescribed(4) excluding some modifications proposed inthis study. All patients had been placed on theoperating table with the chest slightly raised in order to



optimize diaphragm function, and legs raised in orderto avoid sudden hypotension due to Bezold-Jarishreflex. The patients were treated with 0.01 mg fentanylor midazolam 2 mg intravenously (Illustration 11).Standard monitoring was by ECG, SpO2 and NIBP.

After rotation of the patient's head to the other side inrespect to the block, the first step was to mark on theskin the subclavian artery pulsation, at themid-clavicular upper margin (the short red line inillustration 12). From this first landmark, theanesthesiologist drew a vertical line about 2 cm longdirected cranially, then, from the apex of this line,another horizontal line about 2 cm long, directedlaterally; the outer end of the second, horizontal linecorresponds to the needle penetration point.(illustration 13). The inferior belly of the omohyoidmuscle was identified by palpating its skin relief withthe second and third fingers moving slowly upwardfrom the edge of the clavicle, where the muscle slidesforward and up to get to the SCM and then to join theintermediate tendon. The identification of the inferiorbelly of the omohyoid muscle represents an additionaleffort to increase safety, allowing the identification ofthat part of the brachial plexus, situated in a cranialposition in respect to the belly muscle, that has not yetformed the neurovascular bundle. To perform theblock we used a 50 mm long Uniplex Lanoline Pajunk®

22G needle along with a Multistim Sensor Pajunk®

neurostimulator that supplies current from 0 to 60 mAwith a stimulation frequency of 1 or 2 Hz. After localanesthesia of the skin, the needle directed in a dorsal,cranial and medial direction, penetrated theinterscalenic sheath above the omoclavicular trianglegiving the feeling of a “fascial click”. After appropriatemuscle response (shoulder abduction, forearm flexion,etc) to appropriate electrical stimulation (0.5 mA), 30ml of bupivacaine 0.5% were injected within 120seconds. In many patients it was possible to observe,during the local anesthetic administration, theformation of a typical “sausage swelling” between theanterior and meddle scalene muscles, meaning acorrect distribution of the local anesthetic into the IS(illustration 14). The angles formed by the stimulatingneedle with the transverse and frontal planes, passingthrough the point of needle penetration, wereevaluated after appropriate muscles twitch response.The extension of skin surface anesthesia wasassessed by pinprick test, as usual. The evaluations ofthe skin sensitivity of C3, C4, C5, C6, C7, C8-T1

dermatomes were made every 5 minutes for 30minutes after the end of the local anesthetic injection.In patients who had not achieved complete analgesia30 minutes after the local anesthetic injection, theblock was evaluated for another 15 minutes. The block

was considered a failure when, after 45 minutesfollowing the local anesthetic injection, the patientcontinued to perceive the pinprick sensation evokedby the needle. Statistical surveys. The data obtainedwere expressed as average ± SD and, wherenecessary, the statistical evaluation was performedusing χ2 adjusted according to Yates.

Results

The needle’s angles to perform the block were higherto the frontal plane and lower to the transverse plane.In dorsal needle orientation, angle values rangedbetween +10 and +20 degrees to the frontal plane; incranial needle orientation, angles ranged between -2and -8 degrees to the transverse plane going acrossthe cutaneous penetration point. The average valuesof the angles to the frontal plane were about 14degrees and those to the transverse plane were about-5 degrees approximately. Identification of theomohyoid muscle was positive in approximately 75%of patients, indicating that this anatomical landmark isreliable, although not always identifiable; the blockfailure rate was about 8%. In the first 30 minutes, theManani’s technique caused a rapid onset of the blockin the C3, C4 and C5 cutaneous innervation areas anda slower onset of block in C6, C7, C8-T1 cutaneousinnervation areas. Illustration 15 shows the evolutionof the block in the C3 and C4 dermatomes of thecervical plexus and in C5, C6, C7, C8-T1 dermatomesof the brachial plexus in the first 30 minutes after theinjection of local anesthetic. In the 15 minutes after thelocal anesthetic injection, the trend towards thecomplete block was higher in the innervation areas ofC3, C4 and C5, with respect to C6, C7, C8-T1. 15minutes after the onset of anesthesia, the number ofpatients who had a complete block in C5 was found tobe greater than in C3 (χ2 = 4.4, p <0.05), C6 (χ2 = 31 ,4, p <0.01), C7 (χ2 = 29.2, p <0.01) and C8-T1 (χ2 =34.4, p <0.01). After 30 minutes, the same effect wasfound to be greater than C7 (χ2 = 7.2, p <0.01) andC8-T1 (χ2 = 37.4, p <0.01). These results indicate thatthis technique is to be preferred for shoulder andclavicle surgery.

Discussion

A recent survey carried out to describe brachial plexusanesthesia techniques(28) has shown that IS andcervical paravertebral approaches ensure a higherpercentage of success in shoulder and proximalhumerus surgery and that the differences between



IBPBT and SPBPBT are related to the local anestheticinjection onto the nervous and neurovascularcompartments respectively. Previous studies byWinnie and Collins(9) performed after a carefulre-evaluation of the brachial plexus anatomy and byapplying the subclavian perivascular space conceptdeveloped SPBPBT. At the same time Burnham(47) andEather(48) confirmed this concept by describing thesame technique performed at the axilla and obtainedby administering large volumes of local anesthetic intothe axillary neurovascular compartment. The IBPBTMcauses an extension of anesthesia comparable to thatobtained with the IBPBT described by Winnie.(17) Ourtechnique offers a complete anesthesia of the cervicalplexus' lowest roots and the highest roots of brachialplexus which are necessary to perform shouldersurgery.(50-52) The high rate of success of this techniquecomes from having identified a plane were the needlelies in relation to the frontal plane, passing betweenthe anterior and medium scalene muscle and beingdirected anteriorly and externally according to anaverage angle of 10-20 degrees. The angle of theneedle to the transverse plane, variable from -2 to -10degrees, allows us to reach the IS cranially atsomewhat higher levels, compared to the point ofcutaneous penetration. Therefore with our technique,after injection of local anaesthetic through the ISsheath in a point slightly lower than that indicated byWinnie,(17) we obtain a cervico-brachial plexus block (20)

useful for shoulder and clavicle surgery. Concluding, inorder to obtain a cervico-brachial surgical anesthesiadistribution, the important factors include: correctexecution of the block, continued use of the technique,good anatomical knowledge.53

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Illustrations

Illustration 1

1



Illustration 10. Patients and surgery features. Average ± SD.

Anthropological characteristics / Pathologies Numbers Surgicalprocedures

Patients (n)Age (years)Gender (M / F)Weight (kg)Height (cm)ASA (1/2/3)

PathologiesHumeral neck fractureRotator cuff tearHumeral shaft fractureClavicle fractureSupraspinous ligament tear

8063.2 ± 10.824/5663.6 ± 9.6162.4 ± 4.921/51/8

3821127 2

OsteosynthesisArthroscopyOsteosynthesisOsteosynthesisArthroscopy

Legend: ASA = American Society of Anesthesiologists



Illustration 11. Characteristics of anesthesia management. Average±SD.

Patients (n) 80

Preanesthesia: fentanyl/midazolam 46/34

Posture: semi-recumbent 80

Skin wheal (yes/no) 76/4

Omohyoid muscle inferior belly identification (yes/no) 64/16

Fascial click (yes/no) 73/7

Bupivacaine 0.5% 80

Volumes: 30/40 ml 69/11

Injection time (sec) 109 ± 7.6

Needle angle to transverse plane -5.1 ± 1.3 °

Needle angle to frontal plane 14.0 ± 5.2 °

Block failures (yes/no) 6/74



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